Authorization for Release of Information

Authorization for Release of Information
I hereby authorize the Teal Door Counseling Center to:
Release Information ToObtain Information From
Name*
Address
Phone*
The information requested or authorized for release or exchange pertains to:
Mental HealthEducationHIV/AIDSSexually Transmitted DiseasesDrug or Alcohol Abuse
This authorization is valid for 1 year from the date below. I may cancel this authorization by signing, dating, and writing "CANCEL" on this original form or by sending a written, signed and dated request to the provider above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it, my provider has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my mental health evaluation or treatment.
Client Name*
Date of Birth*

MonthDayYear
Signature*

Clear
Date*

MonthDayYear
Date
Name
Relationship to Client*
18 Miller Road|Mahopac, NY 10541
Should be Empty: